How To Use CPT Code 51600

CPT 51600 describes the injection procedure for cystography or voiding urethrocystography. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51600?

CPT 51600 can be used to describe the injection procedure for cystography or voiding urethrocystography. This code is used when a healthcare professional performs an X-ray examination of the bladder and urethra while the bladder is emptying. It is typically done to detect reflux by observing the flow of contrast liquid during urination.

2. Official Description

The official description of CPT code 51600 is: ‘Injection procedure for cystography or voiding urethrocystography.’

3. Procedure

1. A urinary catheter is inserted through the urethra into the bladder.
2. A radiopaque liquid (contrast or contrast agent) is injected.
3. Under the guidance of a fluoroscope, the physician observes the filling and voiding of the bladder.
4. If the contrast flows from the bladder into the urethra during voiding, it is considered normal.
5. If the contrast moves into the ureters and the kidney, it may indicate vesicoureteral reflux.
6. Finally, the catheter is removed.

4. Qualifying circumstances

CPT 51600 is performed when a healthcare professional needs to examine the bladder and urethra during voiding to detect reflux. It is typically done to diagnose vesicoureteral reflux. The procedure requires the insertion of a urinary catheter and the injection of a radiopaque liquid. It is performed by a physician under the guidance of a fluoroscope.

5. When to use CPT code 51600

CPT code 51600 should be used when a healthcare professional performs an injection procedure for cystography or voiding urethrocystography. It is specifically used when the examination is done while the bladder is emptying to detect reflux. This code should not be used for other types of cystography or urethrocystography procedures.

6. Documentation requirements

To support a claim for CPT 51600, the healthcare professional must document the following information:

• Reason for performing the procedure
• Details of the injection procedure, including the type of contrast used
• Observations made during the examination, such as the flow of contrast and any reflux detected
• Date and time of the procedure
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 51600, ensure that the procedure is performed by a qualified healthcare professional and that the documentation requirements are met. This code should not be reported with codes for radiological supervision and interpretation (e.g., 74430, 74455). It is important to consider the location of the testing, as it may affect how the procedure is coded.

8. Historical information

CPT 51600 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare professional performs an injection procedure for cystography to detect reflux in a patient with recurrent urinary tract infections.
2. A physician uses voiding urethrocystography to examine the bladder and urethra of a patient with urinary incontinence.
3. A radiologist performs a cystography procedure to assess the bladder function of a patient with a history of bladder stones.
4. A urologist uses voiding urethrocystography to evaluate the effectiveness of a patient’s bladder training program.
5. A healthcare professional performs an injection procedure for cystography to diagnose vesicoureteral reflux in a pediatric patient with urinary abnormalities.
6. A physician uses voiding urethrocystography to assess the bladder and urethra of a patient with suspected urethral stricture.
7. A radiologist performs a cystography procedure to evaluate the bladder function of a patient with neurogenic bladder.
8. A urologist uses voiding urethrocystography to assess the bladder and urethra of a patient with recurrent urinary retention.
9. A healthcare professional performs an injection procedure for cystography to detect reflux in a patient with a history of kidney stones.
10. A physician uses voiding urethrocystography to evaluate the bladder and urethra of a patient with urinary urgency and frequency.